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A failed vaccination programme, a lack of experience, inadequate communication, a confused response and a lack of immediate action are just some of the findings contained in a scathing review into last year's measles outbreak in Auckland.
The outbreak ripped through South Auckland, infecting as many as 2,000 people, 750 of whom were hospitalised. It's also likely to have spread from here to Samoa, where it proved deadly.
The Pacific community in Auckland was hit the hardest. Pasifika were infected at 14 times the rate of Pakeha.
The review, released by New Zealand's Ministry of Health yesterday, says the outbreak was largely preventable - and came about because no real action was taken to fix a large vaccination gap.
When an outbreak came, health authorities were slow to distribute vaccines or contact trace, and years of restructures at agencies meant there was no one capable of leading a response.
South Auckland GP and chair of the Pasifika GPs network, Api Talemaitoga, says the report laid out what Pasifika health workers had been warning about for years.
Dr Api Talemaitoga. Photo: GREG BOWKER VISUALS